The NHS letter urges hospitals to ‘make the best use of resources’ as well as providing safe care.
Photograph: David Levene for the Guardian

The NHS has been accused of backtracking on improvements in patient safety made after the Mid Staffs scandal by reducing the number of nurses on wards because of its growing financial crisis.

NHS bosses have told hospitals they no longer have to ensure that one nurse is caring for no more than eight patients at a time, in order to help tackle a £2bn black hole that has left 80% of hospitals facing deficits of up to £100m each.

The letter states: “We would stress that a 1:8 ratio is a guide not a requirement. It should not be unthinkingly adhered to. Achieving the right number and balance of clinical and support staff to deliver quality care based on patient needs in an efficient way that makes the best possible use of available resources is the key issue for provider [hospital] boards.”

The move, set out in a letter to all hospital chiefs, has sparked fears that patient safety will be sacrificed to help hospitals cut costs. It makes clear that financial considerations are deemed to be as important as the safety and quality of care patients receive when deciding how many nurses should be on duty.

Cash-strapped hospitals may be tempted to cut their nurse staffing levels as a result of the new advice, the Royal College of Nursing (RCN) warned. Staffing takes up 70% of the NHS’s budget and its bill for employing temporary staff to plug gaps in rotas, especially expensive agency nurses, has hit £3.3bn in the last two years.

The letter has been signed by NHS England, the Care Quality Commission, the National Institute for Health and Care Excellence (Nice), and the regulator NHS Improvement. It recommends that hospitals can ask health professionals, such as physiotherapists, to help look after patients, and use technology to monitor their condition, to reduce the need for nurses on duty.

It urges hospitals “to take a rounded view of staffing” that shows they are “making the best use of resources” as well as providing safe care. It lists a set of variables, including how ill patients are, and then adds: “In some cases these factors will mean a higher number of nurses per patient, and in other cases it will mean a lower number or different configuration of staff can be justified.”

It adds: “It is therefore important to look at staffing in a flexible way which is focused on the quality of care, patient safety and efficiency rather than just numbers and ratios of staff.”

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The NHS is under heavy pressure from ministers to make £22bn of “efficiency savings” by 2020 to help plug the £30bn gap expected to have developed in its finances.

The new advice is a substantial downgrading of guidelines produced only last year by Nice, which insisted that no nurse should look after more than eight patients to ensure good, safe care. That ratio was widely hailed as a way of avoiding a repeat of the Mid Staffs scandal, in which a lack of nurses was found to be a key cause of the appalling care.

Howard Catton, the RCN’s head of policy, said: “There’s a risk that people in the NHS may interpret this letter as a green light to row back on safe staffing when the NHS’s finances are in the perilous state that they are.”

However, he added that other suggestions in the letter, such as allowing hospital managers to use their professional judgment about how many nurses were needed and not rigidly applying fixed ratios, were “common sense”.

Labour said the NHS circular showed that patient care could be put at risk as a result of the fast-ballooning deficit.

“The idea that hospitals can ignore safe-staffing guidance will alarm patients. Safe staffing levels are essential for patient safety and were a key recommendation of the Francis report,” said Heidi Alexander, the shadow health secretary.

“If ministers attempt to balance the books in the NHS by cutting staff and putting patients at risk, then Labour will oppose them all the way. It is yet further evidence that the financial crisis in the NHS is now a real threat to patient care.”

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Ian Wilson, chair of the British Medical Association’s representative body, said: “Adequate staffing levels are vital to deliver safe, high-quality patient care. Flatline funding at a time of rising demand has left services and the frontline staff who deliver them under enormous pressure. The solution is not to stretch existing staff even further, but to ensure the NHS has the resources needed to deliver safe care.”

But hospital bosses welcomed the move away from the 1:8 ratio. “NHS England boss Simon Stevens deserves credit for persuading Jeremy Hunt to soften his previous hard line on safety at any cost. We need to be pragmatic in the face of spiralling deficits,” one told the Guardian .

“It will give more discretion to senior nursing colleagues, giving them a vote of confidence. A ‘one size fits all’ is not the solution to staffing levels; it is about empowering frontline leaders.”

Canadace Imison, director of healthcare systems at the Nuffield Trust thinktank, said: “This letter shows a welcome attempt by NHS regulators to deliver a consistent message about safe staffing levels. It also rightly recognises that the 1:8 nurse to patient ratio is a crude metric and not to be seen as a benchmark.”

But it also leaves NHS trusts no wiser about whether they should under-staff or overspend in order to provide high-quality care, Imison added.